Spontaneous tracheal perforation following a sneeze

Description

Spontaneous tracheal perforation is a rare, potentially life-threatening condition.^1–3 Only a few cases of spontaneous tracheal perforations have been reported.^{2 4} More commonly, tracheal perforations are caused by either iatrogenic or traumatic injuries following a thyroidectomy, traumatic intubation, percutaneous tracheostomy procedure, insertion of an oesophageal stent, oesophageal corrosive injury and sharp and blunt trauma.1 3 5–19 Tracheal perforations may be managed conservatively but often require surgical intervention. This may depend on whether a patient is haemodynamically stable or unstable—based on vital signs being within or outside of normal limits—as well as the site of the perforation.4 5 7 9 10 16 17 Schneider et al performed a retrospective analysis of 29 patients with iatrogenic tracheobronchial injuries.²⁰ They suggest surgical treatment in patients with insufficient mechanical ventilation, an open perforation into the pleural cavity or progressive subcutaneous or mediastinal emphysema. Conservative treatment may be chosen in patients with the following positive features:

• A small (2–3 cm) tear (preferably of the cervical trachea).

• Uncomplicated mechanical ventilation without any loss of tidal volume.

• A laceration sufficiently covered by the oesophagus.

• Mild emphysema with no progress during ventilation.

We report a tracheal perforation following sneezing, which, to our knowledge, has not been reported before. Normally, the pressure in the upper airways during sneezing is 1–2 kPa; however, if the mouth and nose are closed, the pressure may increase by up to 20 times.^{21 22}

A man in his 30s, with a background of allergic rhinitis, experienced severe neck pain immediately after an episode of sneezing when he stifled the sneezes by pinching his nose and closing his mouth. This took place while he was driving a car with a seat belt on. On presenting at the accident and emergency department, he denied any dyspnoea, dysphonia or dysphagia. On examination, his neck was swollen bilaterally, with mild crepitus on palpation and a reduced range of movement of the neck. There were no abnormal findings in the pharynx or larynx on direct visualisation with a flexible nasendoscope. Lateral soft tissue neck X-ray revealed surgical emphysema (figure 1). Immediately following the X-ray, CT of the neck and chest with contrast revealed a 2 mm × 2 mm × 5 mm tracheal tear at the level between the third and fourth thoracic vertebrae, with pneumomediastinum and surgical emphysema of the neck (figure 2).

Figure 1.

Lateral soft tissue neck X-ray. A white arrow points to the surgical emphysema in the superficial neck space. A black arrow points to the surgical emphysema in the retropharyngeal space.

Figure 2.

CT neck and thorax with contrast (A) sagittal view. A white arrow points to the posterior tracheal tear at the level of the third and fourth thoracic vertebrae and yellow arrows point to the surgical emphysema of the neck. (B) Axial view. A white arrow points to the tracheal tear.

He was treated symptomatically for pain with 1 g of paracetamol and 30 mg of codeine, as required. For allergic rhinitis and nasal congestion, he was prescribed 10 mg of cetirizine once a day, 200 mg of fluticasone propionate drops in each nostril twice a day and three drops of xylometazoline hydrochloride 0.1% in each nostril three times a day. No antibiotics were administered. The cardiothoracic surgeons were contacted for their opinion, and it was felt that no surgical intervention was indicated as the patient was systemically well with normal heart and respiratory rate, normal blood pressure, oxygen saturation and body temperature. As a precaution, he was kept nil by mouth for the first night in case he deteriorated and required a general anaesthetic for intubation.

He remained as an inpatient on the ward for close observation for 48 hours. During this time, he did not require additional treatment or interventions to those described above, including oxygen therapy and admission to a high-dependency or intensive care unit as he remained clinically stable with normal vital signs during the inpatient stay.

He was discharged home with analgesia and long-term allergic rhinitis treatment with advice to avoid strenuous physical activities for 2 weeks and stifling sneezes by pinching the nose with the mouth closed. A follow-up CT scan of the neck and chest was performed 5 weeks later, revealing complete resolution of the surgical emphysema with no tracheal tear or any tracheal abnormality.

We suspect the trachea perforated due to a rapid build-up of pressure in the trachea while sneezing with a pinched nose and closed mouth.

Learning points.

• Everyone should be advised not to stifle sneezes by pinching the nose while keeping the mouth closed as it can result in tracheal perforation, as reported here.

• Lateral soft tissue neck X-ray is useful in detecting surgical emphysema, but CT neck and chest with contrast is required to identify the location of the tracheal tear.

• Conservative management of tracheal tears is an option in clinically stable patients not requiring mechanical ventilation with small tracheal tears. The patients must be closely monitored as inpatients for 24–48 hours for any deterioration.

Ethics statements

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